Prostate Mapping for Cancer Diagnosis: The Madrid Protocol. Transperineal Prostate Biopsies Using Multiparametric Magnetic Resonance Imaging Fusion and Micro-Ultrasound Guided Biopsies.

PURPOSE: We assessed the prostate cancer detection accuracy of transperineal prostate biopsy using multiparametric magnetic resonance imaging/ultrasound fusion targeted biopsy and micro-ultrasound during the same procedure. Micro-ultrasound is a new high-resolution imaging system that allows real-time targeted biopsy. MATERIALS AND METHODS: A total of 194 consecutive patients underwent transperineal prostate biopsies using real-time targeted micro-ultrasound (ExactVu™) and ultrasound fusion targeted biopsy (BiopSee®) in the same procedure, from February 2018 to September 2019. Biopsies were performed using a transperineal needle guide attached to the 29 MHz high-resolution micro-ultrasound transducer. RESULTS: The overall positive rate was 56% (108) for prostate cancer and 42% (81) for clinically significant prostate cancer (Gleason Grade Group greater than 1), and adding micro-ultrasound and magnetic resonance imaging detected significantly more clinically significant prostate cancer than systematic biopsy (p <0.001). Micro-ultrasound found 12 of 108 (11%) prostate cancers that were missed by all other techniques and 11 (92%) were clinically significant prostate cancer. PI-RADS® and PRI-MUS™ (Prostate Risk Identification Using Micro-Ultrasound) were strong predictors of clinically significant prostate cancer in a logistic regression model (AUC 0.76). For prostate specific antigen greater than 4 ng/ml, PI-RADS greater than 3, there was an improvement in detection rate between PRI-MUS 4 and PRI-MUS 5 (52% Gleason Grade Group greater than 1 to 92% Gleason Grade Group greater than 1). No fever or clinical infection was observed and 17 (8.7%) patients presented with minor complications (Clavien Dindo I). CONCLUSIONS: This is the first study using a transperineal approach for micro-ultrasound guided biopsy and multiparametric magnetic resonance imaging fusion biopsy. The results show a high accuracy for prostate cancer and clinically significant prostate cancer diagnosis, without infectious complications. The proposed method should be validated in large randomized clinical trials.

Resection of the Intramural Portion of the Distal Ureter during Transurethral Resection of Bladder Tumors: Predictive Factors for Secondary Stenosis and Development of Upper Urinary Tract Recurrence.

PURPOSE: We analyzed the incidence of and predictive factors for ureteral stenosis and recurrent upper urinary tract urothelial carcinoma after resection of tumors located in the intramural portion of the distal ureter. MATERIALS AND METHODS: We retrospectively analyzed the records of 2,317 patients who underwent transurethral resection of bladder tumor for nonmuscle invasive bladder cancer, including 112 (4.83%) with tumors involving the intramural portion of the distal ureter. Multivariate Cox regression analysis was done to determine predictive factors for ureteral stenosis and recurrent urinary tract urothelial carcinoma. RESULTS: At a mean followup of 56 months 17 patients (15.2%) presented with recurrent upper urinary tract urothelial carcinoma and ureteral stenosis had developed in 13 (11.6%). On univariate analysis previous recurrences were associated with both events. On multivariate analysis tumor size 1.5 cm or greater (HR 4.521, p = 0.023) and T1 tumor stage (HR 8.525, p = 0.005) were independent predictive factors for stenosis. Stage T1 in the bladder (HR 7.253, p = 0.001) and carcinoma in situ in the intramural portion of the distal ureter (HR 6.850, p = 0.005) increased the risk of recurrent upper urinary tract urothelial carcinoma. The main study limitation was the lack of information on vesicoureteral reflux due to the retrospective design. CONCLUSIONS: Involvement of the intramural portion of the distal ureter is uncommon. In patients with nonmuscle invasive bladder cancer and involvement of the intramural portion of the distal ureter a stage T1 tumor and a tumor size 1.5 cm or greater are independent predictive factors for distal ureteral stenosis. Moreover, stage T1 and carcinoma in situ in the intramural portion of the distal ureter significantly increase the risk of recurrent upper urinary tract urothelial carcinoma. The urinary tract should be more closely followed in this patient subgroup.